Provider Demographics
NPI:1316437288
Name:MATHIS, BRENDON CHASE (RBT-17-2922-3)
Entity type:Individual
Prefix:MR
First Name:BRENDON
Middle Name:CHASE
Last Name:MATHIS
Suffix:
Gender:M
Credentials:RBT-17-2922-3
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:15218 RUSSELL AVE
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-2967
Mailing Address - Country:US
Mailing Address - Phone:313-670-7470
Mailing Address - Fax:
Practice Address - Street 1:15218 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-2967
Practice Address - Country:US
Practice Address - Phone:313-670-7470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI17-2922-3106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician